Pelvic Organ Prolapse
As a pelvic floor physical therapist, I see a lot of patients that come in to clinic with fear around the diagnosis of pelvic organ prolapse. I totally get it - Googling this can be absolutely terrifying. My insides are what!?
But I want to reassure you - this is not a death sentence. Conservative treatment is often very successful and allows many to live life without any symptoms. This blog is written to educate on prolapse to improve your understanding, as well as review the conservative measures that are taken to find relief.
What is pelvic organ prolapse?
By definition, pelvic organ prolapse is the descent of one or more of the pelvic organs that can contribute to symptoms of bulging, pressure, heaviness, or feeling like something is falling out.
This is more commonly noted at the end of the day or after being on your feet for an extended period. Some report an increase in symptoms with certain workouts or after going to the bathroom.
Types of Prolapse
Cystocele
Prolapse of the bladder into the anterior vaginal wall. Symptoms can include incomplete bladder emptying, trouble initiating stream, post-void dribbling, pelvic floor heaviness, pressure, dryness, discharge, discomfort, painful intercourse.
Urethrocele
Prolapse of the urethra into the vaginal wall. Symptoms can include incomplete bladder emptying, trouble initiating stream, post-void dribbling, pelvic floor heaviness, pressure, dryness, discharge, discomfort, painful intercourse.
Rectocele
Prolapse of the rectum into the posterior vaginal wall. Symptoms can include incomplete bowel emptying, fecal smearing (wiping over and over), heaviness, pressure, low back pain, discharge, discomfort, painful intercourse.
Enterocele
Prolapse of the small intestine into the vaginal wall. Symptoms can include pelvic pressure, heaviness, low back pain, abdominal pain, digestive complications, discharge, discomfort, painful intercourse.
Rectal prolapse
Prolapse of the rectum into the anus. Symptoms can include pelvic pressure, heaviness, feeling of “sitting on a ball”, digestive complications.
What factors can contribute to prolapse?
Repetitive straining - constipation, chronic cough, long pushing stages of labor
Family history
Hypermobility
Age
BMI
Vaginal births
Instrument-assisted births
Significant perineal/pelvic floor trauma
Hormonal changes from pregnancy
How to treat prolapse conservatively
A couple VERY important things to highlight before getting into treatment:
Severity of prolapse does not correlate to severity of symptoms. You can have a very mild prolapse and experience a lot of discomfort/pressure. You can also have a higher grade of prolapse and be asymptomatic.
You are your OWN subject in this experience. This is a diagnosis that does not have a one size fits all recommendation. Each person will have varying triggers and ways to find relief and improvement. This is why blanket statements like “don’t lift anything over 10 pounds” are not helpful, as well as comparing yourself to others that also have prolapse.
With prolapse or increased pressure, we are looking at where your symptom threshold is. At what point during your day, during your workouts, or with what activities in particular do you become symptomatic. If there is a general pattern or threshold that we can establish, we use this knowledge and work under that threshold. Trying not to push through symptoms of heaviness.
We also use this feedback to determine what could be causing the symptoms? Has your body reached a state of fatigue? With fatigue is there compensation? An example, are you standing for long periods of time and end up tucking your butt and clenching to perform this activity?
We are going to review two areas of conservative management: non-exercise and exercise. Combining recommendations in both areas is the best way to achieve relief.
Non-Exercise Management:
Diet
Adequate Hydration
Water intake should be at LEAST half your body weight in ounces. Preferable more if you are breastfeeding and/or exercising. This is key to managing bowel movements to make them less hard and less likely to strain.
Fiber Intake
Aim to consume 25-35 g of fiber each day. Most Americans do not get adequate fiber intake each day even if you eat healthy! Take a look at what you are consuming. Grains, beans, many vegetables, fruits, nuts and seeds are all good places to start when seeking more fiber. Soluble fiber helps stool bulk and insoluble fiber helps with GI motility.
Managing Bowel and Bladder Issues
In order to decrease prolapse symptoms, you need to learn how to pee and poop. Symptoms worsen when you have to chronically strain - such as the case for constipation or incomplete bladder emptying.
Pelvic Floor Lengthening
Peeing and pooping are both situations that the pelvic floor should be relaxed and lengthened. You want to make these as passive as possible so that the sphincters that hold in pee and poop relax for a successful void.
Sit on the toilet. Place your feet on a Squatty Potty or step stool so your hips are higher than knees. Focus on taking deep breaths where you literally think about inhaling into the anus. Feel the expansion that happens when you take that inhale. If you need to push (ideally we don’t have to), exhale like you are blowing on hot coffee and gently push down.
Splinting
Sometimes with a rectocele, the lack of support at the posterior vaginal wall can make it difficult for stool to pass. Splinting with your finger or a tool (google Femmeze) to provide support at the posterior vaginal wall can easily relieve symptoms. You would insert into the vagina and push back towards the rectus - this pressure will feel like you can be more productive with the bowel movement.
Internal and External Support
Internal Support
A pessary is a removable device that is inserted into the vagina to provide support to the vaginal wall. They come in different shapes and sizes and are prescribed to suit your anatomy and symptoms.
Sometimes inserting a tampon or Poise Impressa puts support into the vaginal wall also temporarily relieving symptoms when it is in. This is not a long term solution but a way to get some relief on days that are particularly irritating.
External Support
Bands like the V2 Supporter can be worn over underwear to provide compression and support to the pelvic floor.
Exercise Management:
Managing Pressure
Posture/Position
We need to understand that certain postures lead to changes in pressure distribution. Many will feel increased pelvic pressure with tucking butt/leaning back and relief of symptoms when stacking ribcage over pelvis in a more “neutral” zone.
I recommend checking in with yourself during activities that cause symptoms. When you carry your child, wear your baby, stand in the kitchen washing dishes, etc. What does you posture look like? Is your butt tucked and ribcage shifted back? Aim to align that ribcage over your pelvis WITHOUT feeling like you have to clench other muscle groups.
Breathing Strategies
One way to help manage pressure with exertion is to introduce “exhale on effort”. Instead of straining and bearing down, focus on blowing out through the more effortful full range of motion.
Example: doing a weighted squat and exhaling through the full range, inhaling at the top. Another example, exhaling as you lift your baby out of the crib or tub.
Decreasing Unnecessary Tensions
Decreasing overall body tension is also key to managing pressure. Prolapse symptoms often worksen in those that clench their glutes consistently. Do periodic check-ins: are your glutes unclenched? Is your jaw relaxed? Let go of your shoulders and your belly.
Strengthening
You absolutely should continue to strength train despite having a prolapse diagnosis. With my clients, we develop a program with exercises that allow them to stay asymptomatic, build strength, and gradually progress. We can’t expect daily movement to get less symptomatic if we never build resilience around it.
Prioritize strengthening muscles outside of the pelvis: hamstrings, quads, inner thighs, glutes, abdominals, hip flexors, etc. If standing exercises are symptomatic for you, what does it look like to use a wall for support, or perform them on a mat in more of a gravity-eliminated position?
Each person will look different so I highly recommend working with a pelvic floor physical therapist to develop an exercise plan that is suitable for you and your symptoms.
When is surgery indicated?
If you have tried conservative measures without improving symptoms or you still feel like your quality of life is affected by prolapse, surgery is an option. This is more often the case for grades 3-4 prolapse. Meeting with a urogynecologist to determine if this is an appropriate route is typically the next step!
I hope this helps provide some education in a space that can feel scary. This is incredible common and absolutely something that physical therapist can help with! You can find a pelvic floor PT local to you at www.pelvicrehab.com.
